No-Scar Transanal Total Mesorectal Excision
This article describes a technique of performing a surgery without a scar. The method is called NOTES, which means, natural orifice transluminal endoscopic surgery. This means that rather than cutting the exposed skin, a natural body opening, such as the mouth, vagina, or anus is used to introduce surgical instruments into the body. Basically, a tube called an endoscope is placed into the opening, advanced towards the target area, and then a camera, a light source, and surgical instruments are put through it to enable surgery. The surgeons were able to manipulate the organs, suture blood vessels, and extract diseased tissue using this method. In this particular case study a total mesorectal excision was performed and they were able to remove a substantial part of the colon.
In this case a 56 year old female patient with a 5-cm long tumor in the middle third of her rectum was chosen as the subject of the experiment. She was given an enema and placed on a surgical table at a 30° incline with her hips flexed at 15° and leg supports to keep her legs in the air. The instruments were advanced through the anus and perform the necessary incision to dissect the diseased portion of her colon. After the dissection, the contents were removed through the anus and then they proceeded to sew the healthy colon to the anus. The recovery was remarkably good and the only pain-medication the patient required was paracetamol. She was drinking fluids almost immediately and was able to eat one day after the operation. She did have mild pain, but was able to walk almost immediately surgery. The patient did not feel well on the third day after surgery, so the physicians performed an imaging study and discovered that it was only a simple hematoma that was causing the discomfort.
This was an elegant and well performed procedure resulting in no visible scars. Other methods of removing this tumor would have combined laparoscopic techniques with a trans-anal approach leaving small scars from where the instruments were introduced trans-abdominally. The biggest fear with this approach would be introducing the bacterial flora of the anus into the body cavity, but this can be well controlled by trained physicians. A more limiting factor is perhaps the costs associated with such a procedure because in order to be performed well high definition cameras and screens must be utilized. Despite the financial drawback, the procedure is very promising because it has the post-operative benefits of minimally invasive surgery while at the same time providing the same benefits as a major removal of body tissues.
Bibliography
Leroy J, Barry B, Melani A, Mutter D, Marescaux J. No-Scar Transanal Total Mesorectal Excision: The Last Step to Pure NOTES for Colorectal Surgery. JAMA Surg. 2013;148(3), 226-230. doi:10.1001/jamasurg.2013.685.
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